Thank you for choosing Dr. Harris as your physician. Please carefully read each statement and sign below. Please note that whether or not you are covered by insurance, you are ultimately responsible for the bill and any unpaid balances that insurance does not pay for. Our office manager will be glad to speak with you if you have any questions.
I understand that I need to bring a current insurance card(s) to each appointment, If I have new insurance, I need to bring a temporary care or proof if insurance. I understand that if I do not have my insurance care, referral, and/or co-payment, that my appointment may be rescheduled until such time that I can provide these.
All balances and copays are due in full at time of service. If not paid, my appointment may be rescheduled and/or fee may be assessed.
I understand that if my insurance plan requires a designated Primary Care Physician (PCP), I will need to notify my insurance of my selection of Dr. Gerald Harris. Failure to do so may cause denial of claims and therefore cause claims to be due/payable by me.
I understand if my account is not paid in full withing 90 days, a $35 collection or processing fee will be added to the outstanding balance each month and may be turned over to a collection agency. I understand that a $35 service fee will be added for any checks deemed insufficient (NSF) I am responsible for the check amount along with the $35 before my future appointments.
I understand that if I am unable to keep a scheduled appointment, I need to give a 24 hour notice. Failure to keep appointments denies other patients the opportunity to see Dr. Harris, therefore, any "No Shows" will result in a $40 no show fee for physician visits. This fee is due/payable prior to the next office visit. This office will allow 45 days from the date of filing for my insurance company to process or pay a claim. AZ Law allows insurance companies operating in the state no more than 30 days to process a claim. Any appealed claims will extend that deadline.
It is my responsibility to provide my insurance company as well as Dr. Harris's office with any needed documentation, forms, ect. in order to process claims. Failure to do so may result in the balance being made due from patient. It is my responsibility to notify Dr. Harris's office of any changes in insurance. If my insurance has changes and proof has not been provided to the office for claims processing, claims may be denied and miss the filing deadline, therefore making balances "due from patient.'
If I have questions about my insurance benefits, I am aware that I can ask to speak with the office manager and schedule an appointment for insurance review. Ultimately, it is up to me, the patient, to know my copays, deductibles, and all other current insurance information. The office manager can address any concerns/questions that may have.
I understand that I have NO insurance coverage, fees are due at the time of service. If I am experiencing Financial hardship, I need to speak with the office manager. The above information is true to the best of my knowledge. I authorize my insurance benefits to be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize Dr. Gerald B. Harris, DO, LLC or insurance/billing company to release any information required to process my claims.
I have read and I understand the above Financial Policy. I agree to abide by its terms.
Signature of Patient/Legal Guardian/Representative _______________________________________